C15019 Authorization Agreement – Bank Draft Tear off lower portion of form and shred after draft has been set up.

Payment Authorization for Bank Draft Use If you use this service to make your payment, you accept these terms and conditions. Please read them carefully.

Refund Policy: Under normal circumstances, there are no refunds on the payments.

Privacy Policy: Your information is secure and will only be used for the purpose of processing this payment transaction.

Late Fees: Monthly drafted payments are processed on the due date and applied to your account each month on the day that your bill is due. If a payment is denied, all late charges will apply. Payments not received by AMUD prior to due date will result in late charges. Any abuse of this privilege will result in automatic removal from the recurring draft payment program.

Prohibited Use: Please note that the Bank Merchant does not accept payments from collection agencies and third-party agencies. The Bank Merchant reserves the right to reverse all such payments if it discovers that they were made from such third-party agencies or collection agencies.

Electronic Checks: You, the consumer, authorize us the right to issue an Electronic Check to your bank. Your authorization on this agreement will give us the right to present a check to you bank for your bill payment.

You agree to the terms and conditions, you agree to pay the bill payment amount to be paid to the billing company. All authorizations are subject to the agreements governing you credit or debit card. Payment transaction will only be completed after receiving successful authorization form your card company for the Total Amount Charged. For card payments and ACH payments, you will see one-line item on your card holder and bank statement- the billing amount charged directly by the billing company you are making a payment to.

AMUD reserves the right to refuse or terminate automatic draft payment services.

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS): Automatic Bank Draft option is available for customers who want their payment deducted directly from their bank accounts. Please call the office to request a Bank Draft Authorization Form or print the form from our web site www.amud.com and return to the AMUD office. Please allow up to 30 days for your account to be activated for ACH Debits. (You may have to send in a payment for the first month). All drafts are processed on the billing due date.

I authorize Acton Municipal Utility District (AMUD) to initiate debit entries to my bank account indicated below at the depository financial institution named below, and to debit the same to such account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authorization is to remain in full force and effect until AMUD has received written notification from me of its termination in such time and in such manner as to afford AMUD and the depository a reasonable opportunity to act on it. I also understand that the account may be subject to late fee charges if bank card authorization is denied.

NOTE: DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.

Signature of Primary on AMUD Account AMUD Account Number Today’s Date

Please Print Name of Primary on AMUD Account Email address

AMUD Service Address Zip Code Phone Number

AMUD Representative

Bank Account Type (Check one): □ Checking account □ Savings account □ Recurring Monthly Charge

PLEASE PRINT CLEARLY

Bank Routing # Bank Account #

Bank Name / Branch Bank City, State Zip

Name on Bank Account